Saturday, May 19, 2007

Q: What do you do when the old stuff you have been saying seems not to be working so well any more--but you don't have anything new to say?

A: Say the old stuff over again, only louder.

At least that seems to be PhRMA's plan. Whenever something happens that challenges the main lobbying group for the nation's big pharmaceutical companies, you can count on a highly placed individual in the organization to appear in the media with a prominent opinion column, reciting the PhRMA party line.

The latest challenge was the Campbell et al. survey of physicians in the New England Journal (http://brodyhooked.blogspot.com/2007/04/new-england-journal-study-shows.html). The industry took quite a beating in the way the media covered that news. That 94 percent of physicians have contact with industry representatives is good, because those contacts provided valuable information about drugs, but don't unduly influence scientific prescribing--well, nobody was buying that story.

So PhRMA trotted out Scott Lassman, its senior assistant general counsel, whose op-ed, "Does a drug firm's free lunch influence doctors?" appeared in the Boston Globe on May 18. Lassman started off by briefly summarizing the Campbell survey, and added a point "ironically and rarely noted in the subsequent media coverage"-- that the investigators paid each physician $20 for participating in the survey. A standard measure these days as fewer and fewer folks respond to mailed surveys; but apparently in Lassman's eyes, it amounted to something sinister. After all, PhRMA gives physicians nice stuff, and then expects them to do what the drug industry wants them to. It only stands to reason that if somebody else is paying the physicians, they might go over to the enemy.

Lassman then proceeds to trot out all the familiar war horses:

"Who knows better about the scientific complexities of prescription medicines than the companies that create them?"

"...it seems to me to be insulting...[to say] that a meeting, a pizza, or a pen would inappropriately influence a physician's prescribing decisions."

A bit off the point, but have you noticed that whenever PhRMA is talking about gifts from drug reps being powerless to sway the scientific practitioner, the gifts always appear in the singular and never in the plural? A pizza. A pen. A doughnut. I guess that old ad was wrong; you can eat just one potato chip. No doubt if the doc ever took two pens, the industry could have its way with him. But the doc, being an abstemious sort of fellow, always takes only one pen, so everything is all right.

Back to Lassman. "This debate is really about trust." Yes, he got that part right. But whereas the media have for the most part drawn the logical conclusion that physicians become less trustworthy when they get their drug information, as well as a bunch of freebies, from biased commercial sources, Lassman wants to stand this idea on its head: "Just as patients trust their physician, it is equally important that physicians trust their pharmaceutical representatives."

Now, you might say that there is no reason on earth why physicians should trust a person who has one and only one job, who has been trained to do that job, and who is paid bonuses strictly based on whether or not he does that job--get the physician to prescribe more of the firm's drug, and push whatever physician's buttons have to be pushed to make that happen. But Lassman is now full of this trust thing, and so proceeds to tell us once again about the "strict" code of ethics imposed by PhRMA "more than four years ago" and that is in keeping with the AMA code of ethics. Now, referring to the PhRMA code of ethics is odd in relation to the Campbell et al. survey, since that survey is one of the most striking pieces of information to date on how widespread may be violations of the PhRMA code of ethics. If gifts are supposed to be modest and related directly to patient care, and some gifts are completely prohibited (such as tickets to sports events), then it would have been very hard for Campbell and company to come up with some of the figures that they came up with.

A few days before Lassman's op-ed appeared in the Boston Globe, a Seattle family physician, Steve Dudley, published a short essay in the Los Angeles Times ("The gifts that keep on giving," May 14). It's a bit hard to track what Dudley is actually saying in this ambiguous narrative. At the end, you don't know whether he has had an "aha" moment regarding how he is being corrupted by the free samples and free lunches the reps shower him with, or whether old habits rise up and drown out the "aha." But my point in bringing Dudley into this is that he has to hurry up to finish his clinic that day because he's due at the ballpark where box seats and free beer and brats await him, courtesy the drug rep. That is as clear a violation as you could wish of the PhRMA and AMA codes of ethics, and here's a doc writing about it in the LA Times as if it's the most normal thing in the world.

Just how well are the PhRMA guidelines being followed? If PhRMA would give us some hard data, instead of warmed-over smoke and mirrors such as Lassman's op-ed, we might actually know something. And don't tell me that the industry that manages to track every prescription written by every doc in the nation has no hard data.

The editorial was pretty hard-hitting in condemning conflicts of interest that are destroying patient trust in physicians, but what especially caught my attention were the readers' comments posted on the website below the editorial. Here is a sampling:***The last three times I visited my doctor, Pharma Reps were setting up breakfast or lunch. Once while sitting in the waiting room, a Rep strolled in and asked the Receptionist if he could get "on the List" to provide breakfast or lunch to the office. She pulled out what I can only assume was an appointment log to keep track of lunch and breakfast appointments for the reps. She gave him a time and he happily went on his way. The office smelled of food all three times. I heard one of the staff say, "What's for lunch?" and another said I don't know but it smells like Mexican food. It appeared to be an everyday thing with this particular group. I stopped going in their office because I always came out with a handful of Rx that I didn't need.***I was recently at my doctor's office. A rep from a pharmaceutical company came in. He was ushered into the front office where he hooked his laptop up to one of the doctor's computers and did a download. After he finished, he thanked them and said, "I'll see you next month", then left. I am in the healthcare field myself and understand the pressures on health care providers to safeguard patient information. [HIPAA] has folks running scared. I had to wonder what kind of incentive would be strong enough to get my doctor to let someone walk in to his office and get unfettered access to one of his computers.***What most struck me about these postings was the way that I think my fellow physicians regard their relationships with drug reps. (I cannot document this with firm data.) It is my impression that physicians, over many years, have gotten used to thinking of what happens between them and the reps as occurring in the "back room." The giving of gifts, the providing of lavish lunches for the office staff, all supposedly happen out of sight of patients. The physician can have his cake (or his sandwich or his pizza) and eat it too. He gets all these freebies but never has to worry about patients seeing what is going on and asking embarrassing questions--or, worse, deciding that they can no longer trust this doc because he seems to be in bed with the industry.

Well, guys, wake up. There is no "back room" any more. All our shenanigans are now clearly visible to the patients. And an increasing number of them don't much like what they see. Check out the Tennessean editorial if you don't believe that.

The article that appeared May 10 in the New York Times is very important because it addresses an issue on which current data is rather lacking--the "proof" that physicians are influenced by benefits received from industry. The hypohesis that physicians will alter prescribing behavior based on goodies, obviously, cannot be studied in a randomized, controlled trial. There is always the possibility of contamination. The available data strongly suggest that the hypothesis is true, and no good evidence tends to disprove the hypothesis. But any further data, even if of questionable quality, helps to make the case.

That is what the Times reporters seem to have done. They took advantage of the legal mandatory reporting system in Minnesota, requiring companies to report payments to doctors. They chose a small slice of medical practice--child psychiatry. They picked one variable that they could find in public data--prescriptions for atypical antipsychotics to children under the state's Medicaid program.

These prescriptions are especially important for a couple of reasons. First, most of these drugs are poorly studied in kids and some experts belive that they are now being greatly overused. (In defense of the docs, we should add that the average Medicaid patient will get a private audience with the Queen of England about as soon as he will get long term, competent psychotherapy; so the docs might reasonably feel that their only choices are to prescribe possibly dangerous drugs off-label, or do nothing at all.) Second, if these drugs are actually effective for anything, it is very likely that cheaper, older antipsychotics are actually just as good as well as being a lot cheaper--tho again, we are not sure when it comes to kids.

So what did the Times reporters find? Between 2000 and 2006, payments to MN psychiatrists from the manufacturers of these drugs rose more than 6 times; and the number of scripts written for these drugs rose more than 9 times. The docs who received at least $5000 from the drug makers appear to have written 3 times as many of those scripts as psychiatrists who received less or no money.

The article went on to describe at length the payment arrangements for these MN psychiatrists. Most of them are paid as members of company speakers' bureaus. From this article, it appears that virtually every child psychiatrist in MN is a member of one of these speakers' bureaus, leaving one to wonder who the audience is--maybe they sit in a big circle and pass the microphone around the table. Actually, it's not quite that bad; the article stated that "more than a third" of MN's licensed psychiatrists took money, so maybe more than half did not.

My personal sleaze award goes to Dr. Suzanne A. Albrecht, from Edina, MN, who earned more than $188,000 over a 3 year period for giving these talks. (She's nothing compared to Dr. Annette M. Smick, near Rochester, who topped the list by earning $689,000 over a 6 year period.) Dr. Albrecht defended herself to the Times by saying, "If someone takes the point of view that your doctor can be bought, why would you go to an E.R. with your injured child and say, 'Can you help me?'"

It's worth taking that comment apart word by word. What is Dr. Albrecht saying? That because all docs are like her, you should not take your injured child to an ER? (Like you have a choice?)Or that because you would take your injured child to an ER, that somehow proves that what she is doing is OK? Dr. A. seems oblivious to the logical conclusion, that if someday, people actually did so lose trust in physicians that they hesitated to take their injured kids to the ER, people like her could look themselves in the mirror and say that they were the reason for this distrust.

Another great quote in the article comes from Dr. Melissa DelBello, a strong advocate of the use of atypical antipsychotics for kids diagnosed with bipolar disorder. Dr. DelBello teaches at the University of Cincinnati, and since she is not from MN, the Times could not find figures on what she was paid as a speaker. "Trust me," she told the reporters, "I don't make much." In Hooked, I used a classic quote from P.G. Wodehouse, "When an Englishman says 'trust me,' it's time to start counting the spoons."

Gardiner Harris, Benedict Carey, and Janet Roberts. "Psychiatrists, Children and Drug Industry's Role." New York Times, May 10, 2007.

Tuesday, May 1, 2007

I had the pleasure recently of hearing from Daniel Carlat, MD, assistant clinical professor of Psychiatry at Tufts University. who describes himself as "a former drug company speaker who 'converted' in 2002." He's now the editor of The Carlat Psychiatry Report, a non-commercially-biased monthly newsletter:

As best as this family physician can tell, the newsletter looks like a very good source of thoughtful apprasial of psychiatric medications, and a potential corrective for marketing hype in a specialty that seems to attract more than its share.